Discussion
Bladder can be found in 1-3% of all inguino-scrotal hernias1. The vast majority of these are small and asymptomatic; they are therefore often diagnosed intraoperatively during routine inguinal hernia repair2. When symptoms do occur, they most commonly consist of two stage urination, in which pressure must be applied to the herniated bladder to completely drain it3. Other symptoms include non-specific lower urinary tract symptoms such as dysuria, urinary frequency and urgency, or a palpable scrotal mass1. Possible imaging modalities to diagnose bladder herniation include non-contrast CT, CT urogram or ultrasound of the urinary tract and scrotum1, however it has been suggested that all patients receive a CT scan at some point due to a weak association with urinary tract malignancy6.
In this case the patient initially presented with acute urinary retention, likely secondary to compression of the urethra below the level of the herniated prostate gland. To our knowledge this has not previously been reported in the literature as an initial presentation of scrotal herniation. This was successfully decompressed with a urinary catheter. While there have been no randomised controlled trials on the subject, it is thought that surgical repair and preoperative catheterisation is indicated in patients with symptomatic scrotal hernias4. However, there is a high risk of damage to the bladder5 and so it was decided to manage this case conservatively.
This patient presented on a second occasion with urosepsis likely secondary to upper urinary tract obstruction given the ultrasound findings of bilateral hydronephrosis. There are few reports of upper tract obstruction secondary to inguinoscrotal hernia in the literature, and these cases are all unilateral6,7. On the patient’s initial discharge it was thought that his bilateral hydronephrosis was secondary to vesicoureteric reflux secondary to acute retention rather than compression of both ureters. Clinicians should therefore be alert to this possibility in future and consider repeat imaging and renal function tests to assess for resolution of obstructive uropathy resulting from a herniated bladder.